— 生理適應 · MEDIUM · MCQ —
護理師評估胸管引流系統時，下列何種情況需立即採取護理措施？
A nurse is assessing a client with a chest tube drainage system. Which finding requires immediate nursing intervention?
- AFluctuation of fluid in the water seal chamber水封瓶內的液體波動
- BSmall amount of sanguineous drainage少量血性引流液
- CThe system is positioned below the client's chest level引流系統置於病人胸部水平下方
- DContinuous bubbling in the water seal chamber✓ 正解水封瓶內持續冒泡
— Explanation · 中文詳解 —
水封瓶持續冒泡（Continuous bubbling）通常代表系統存在空氣洩漏（Air leak），若排除管路連接不緊密的問題，需立刻回報醫師。A 為正常呼吸波動，B 為術後常見引流，C 為維持引流功能的正確位置。
Continuous bubbling in the water seal chamber typically indicates an air leak in the system; once a loose tubing connection has been ruled out, the provider must be notified immediately. A represents normal respiratory fluctuation, B reflects a common postoperative finding, and C is the correct position to maintain drainage function.
✦ 台美臨床差異
胸管照護在兩地皆為常規，但在美國護理師常需自行判斷是否需要進行空氣洩漏測試。